A client on a mental health unit develops flu-like symptoms and low blood pressure. After reviewing the client's history, it was noted that the client has a diagnosis of schizophrenia and is currently taking risperidone (Risperdal). The nurse should recognize that which of the following adverse effects may be occurring?
Neuroleptic malignant syndrome.
Tardive dyskinesia.
Acute dystonia.
Pseudoparkinsonism.
The Correct Answer is A
Choice A rationale:
Neuroleptic malignant syndrome (NMS) is a potentially life-threatening condition that can occur as a severe adverse effect of antipsychotic medications, such as risperidone (Risperdal). Symptoms of NMS include flu-like symptoms (fever, muscle rigidity, and sweating) along with altered mental status, and autonomic dysregulation. It's crucial for the nurse to recognize this potentially fatal condition promptly and intervene appropriately.
Choice B rationale:
Tardive dyskinesia is a movement disorder that is often a result of long-term use of antipsychotic medications, but it is characterized by repetitive, involuntary movements of the face and other body parts. It doesn't typically present with flu-like symptoms or low blood pressure.
Choice C rationale:
Acute dystonia is characterized by involuntary muscle contractions and spasms, often involving the muscles of the face, neck, and back. It usually occurs shortly after starting antipsychotic treatment. While it can cause discomfort, it doesn't present with flu-like symptoms and low blood pressure as described in the scenario.
Choice D rationale:
Pseudoparkinsonism, also known as drug-induced parkinsonism, is characterized by symptoms similar to Parkinson's disease, such as tremors, bradykinesia (slowness of movement), and rigidity. It doesn't typically cause flu-like symptoms and low blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
A client requesting extra blankets due to a room temperature discrepancy is not indicative of delirium. This behavior may simply stem from feeling cold, which is a logical response to a temperature below the client's comfort level.
Choice B rationale:
A client attempting to climb out of bed and repeatedly stating a need to get home is a manifestation of delirium. Delirium is characterized by sudden disturbances in consciousness and cognitive function, leading to confusion and altered perception. The client's behavior suggests a disoriented state and a distorted perception of reality.
Choice C rationale:
A client refusing to get out of bed and lacking motivation for daily hygiene might not necessarily indicate delirium. These symptoms could be related to other factors, such as depression or physical discomfort, which are not specific to delirium.
Choice D rationale:
A client wanting to know the current time when there is a visible clock on the wall doesn't indicate delirium. It might just reflect the client's desire to know the time, which is a common behavior and doesn't directly relate to cognitive disturbances associated with delirium.
Correct Answer is A
Explanation
The correct answer is choice A: "Assess the client's need for assistance with ADLS."
Choice A rationale:
Safety is the top priority when caring for a client with major depressive disorder. Assessing the client's ability to perform Activities of Daily Living (ADLS) helps determine her level of functioning and any potential risks. Ensuring that the client can meet her basic self-care needs is essential for her well-being.
Choice B rationale:
Encouraging the client to create her own schedule of daily activities can be a valuable intervention, but it should come after addressing safety concerns. Choice A takes precedence as it directly relates to the client's immediate well-being.
Choice C rationale:
Teaching the client to use passive communication is not appropriate. Passive communication may hinder the client's ability to express her needs and advocate for herself. Assertive communication skills are more beneficial for her overall mental health.
Choice D rationale:
Isolating the client from unit activities may exacerbate her feelings of depression and loneliness. Encouraging engagement with appropriate unit activities and social interactions can contribute to her sense of belonging and aid in her recovery.
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